Efficacy of Corticosteroid Therapy for HTLV-1-Associated Myelopathy: A Randomized Controlled Trial (HAMLET-P)

Corticosteroids are most commonly used to treat HTLV-1-associated myelopathy (HAM); however, their clinical efficacy has not been tested in randomized clinical trials. This randomized controlled trial included 8 and 30 HAM patients with rapidly and slowly progressing walking disabilities, respectively. Rapid progressors were assigned (1:1) to receive or not receive a 3-day course of intravenous methylprednisolone in addition to oral prednisolone therapy. Meanwhile, slow progressors were assigned (1:1) to receive oral prednisolone or placebo. The primary outcomes were a composite of ≥1-grade improvement in the Osame Motor Disability Score or ≥30% improvement in the 10 m walking time (10 mWT) at week 2 for rapid progressors and changes from baseline in 10 mWT at week 24 for slow progressors. In the rapid progressor trial, all four patients with but only one of four without intravenous methylprednisolone achieved the primary outcome (p = 0.14). In the slow progressor trial, the median changes in 10 mWT were −13.8% (95% CI: −20.1–−7.1; p < 0.001) and −6.0% (95% CI: −12.8–1.3; p = 0.10) with prednisolone and placebo, respectively (p for between-group difference = 0.12). Whereas statistical significance was not reached for the primary endpoints, the overall data indicated the benefit of corticosteroid therapy. (Registration number: UMIN000023798, UMIN000024085)

Effect of pulsed intravenous methylprednisolone with alternative low-dose prednisone on high-risk IgA nephropathy: a 18-month prospective clinical trial

Full-dose prednisone (FP) regimen in the treatment of high-risk immunoglobulin A nephropathy (IgAN) patients, is still controversial. The pulsed intravenous methylprednisolone combined with alternative low-dose prednisone (MCALP) might have a more favorable safety profile, which has not been fully investigated. Eighty-seven biopsy-proven IgAN adult patients and proteinuria between 1 and 3.5 g/24 h after ACEI/ARB for at least 90 days were randomly assigned to 6-month therapy: (1) MCALP group: 0.5 g of methylprednisolone intravenously for three consecutive days at the beginning of the course and 3rd month respectively, oral prednisone at a dose of 15 mg every other day for 6 months. (2) FP group: 0.8–1.0 mg/kg/days of prednisone (maximum 70 mg/day) for 2 months, then tapered by 5 mg every 10 days for the next 4 months. All patients were followed up for another 12 months. The primary outcome was complete remission (CR) of proteinuria at 12 months. The percentage of CR at 12th and 18th month were similar in the MCALP and FP groups (51% vs 58%, P = 0.490, at 12th month; 60% vs 56%, P = 0.714, at 18th month). The cumulative dosages of glucocorticoid were less in the MCALP group than FP group (4.31 ± 0.26 g vs 7.34 ± 1.21 g, P < 0.001). The analysis of the correlation between kidney biopsy Oxford MEST-C scores with clinical outcomes indicated the percentages of total remission was similar between two groups with or without M1, E1, S1, T1/T2, and C1/C2. More patients in the FP group presented infections (8% in MCALP vs 21% in FP), weight gain (4% in MCALP vs 19% in FP) and Cushing syndrome (3% in MCALP vs 18% in FP). These data indicated that MCALP maybe one of the choices for IgAN patients with a high risk for progression into ESKD.Trial registration: The study approved by the Chinese Clinical Trial Registry (registration date 13/01/2018, approval number ChiCTR1800014442, https://www.chictr.org.cn/).

Safety Comparison of Conventional Versus Extended Infusion of Pulse Methylprednisolone in Multiple Sclerosis Exacerbation Retrospective Study

Objective: - To ascertain the adverse events and changes in vital signs (heart rate (HR), systolic (SBP), diastolic blood pressure (DBP), and serum potassium level during and after intravenous methylprednisolone (IVMP) in multiple sclerosis exacerbation.Design: retrospective review study conducted at Hamad General Hospital (HGH), all patients who are admitted 2019-2020 with MS exacerbation without any other comorbidities will be categorized into 2 groups depending on infusion rate, one group received conventional intravenous methylprednisolone pulse dose over 30minutes to one hour, while the second group received methylprednisolone pulse dose intravenously over an extended period)(four to six hours). Multiple readings of vital signs and, potassium level through steroid administration time will be assessed to determine if there is an infusion-related significant difference in adverse events between both groups.Methods: 74 adult patients with MS relapse who have been admitted at Hamad General Hospital (HGH) and satisfied pre-specified inclusion criteria were invited to participate in the study.Results: 74 patients with MS included in the study, 61 patients (83.6%) were received methylprednisolone dose 500 mg -1000 mg in conventional infusion rate while 12 patients (16.4%) were received pulse steroid in extended duration. There was no significant difference in mean blood pressure before and after IVMP in both groups. There was a small but statistically significant increase in mean heart rate in the conventional group immediately after first and second but not 3rd dose of IVMP compared to baseline 3.5± 8.9 and 4.85± 13.9 P < 0.003. There was a minimal non-significant increase in potassium level in the conventional group (P = 0.17), while there is a non-significant decrease in potassium level in the extended group (P=0.72).Conclusion: IVMP is considered safe and effective in the treatment of MS exacerbation regardless of intravenous infusion duration. There was no significant difference in vital signs among different infusion rates. However, there was a small but statistically significant increase in mean heart rate in the conventional group immediately after first and second but not 3rd dose of IVMP compared to baseline. No significant difference was observed in potassium levels before and after IVMP. We, therefore, recommend that potassium level monitoring should be only restricted to patients with other risk factors of hypokalemia.

MOG-antibody-associated longitudinal extensive myelitis after ChAdOx1 nCoV-19 vaccination

This case report describes a 59-year-old man with myelin oligodendrocyte glycoprotein (MOG)-positive longitudinal extensive transverse myelitis (LETM) after being vaccinated with the COVID-19 vaccine ChAdOx1 nCoV-19. He presented with urinary retention, gait disturbance, hypoesthesia and brisk reflexes in his lower extremities without paresis. Due to the ineffectiveness of high-dose intravenous methylprednisolone, therapeutic plasma exchange was performed, gradually improving the patient’s condition. Vaccination as a trigger for an excessive immunological response seems plausible, though unspecific for the ChAdOx1 nCoV-19 vaccine.

Role of Pre-operative Intravenous Methylprednisolone for Post-operative Pain Control after IFF Surgery

Background: Intertrochanteric region are common in older ages. 33% females and 15% males in their 90s suffer from hip fracture, most commonly intertrochanteric fractures (50%). The pain associated with the surgery of the intertrochanteric fractures is quite troublesome and reduces patient mobilization thus increasing morbidity. Aim: To compare preoperative intravenous methylprednisolone vs control in terms of mean VAS score in patients presenting with intertrochanteric femur fractures. Study design: Randomized control trial Place and duration of study: Orthopaedic Department & General Surgery Department POF Hospital Wah Cantt and Izzat Ali Shah Hospital Wah Cantt from 1st Jan 2020 till 31st Dec 2020 Methodology: Sixty patients were enrolled and divided in two groups. Thirty patients in methylprednisolone group and 30 patients in control Group were enrolled. Age 40-75 years old people of both genders with intertrochanteric femur fractures were included. Post-operative pain was recorded at resting position and 45° hip flexion position 24 hours post-surgery through VAS. Results: In group A, 18 patients were males and 12 were female. In group B 19 patients were male and 11 were female. Mean age in group A was 56.37±4.56 years and in group B, 55.89±4.13 years. Mean VAS pain score in the control group was 5.03±1.542 while the mean VAS pain score in the treatment group was 3.70±15.79 (P=0.002). Conclusion: Methylprednisolone preoperatively reduces postoperative pain at 24 hours after surgery in patients undergoing intertrochanteric fracture fixation. Keywords: Methylprednisolone, Preoperative, Visual Analogue Scale, Pain, Postoperative’

Acute Disseminated Encephalomyelitis in a 2-Year-Old Patient Following COVID-19

This report presents the case of acute disseminated encephalomyelitis in a 2-year-old patient following a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test. She presented with ataxic gait, truncal ataxia, and reduced coordination following 10 days of intermittent fever and lethargy. She did not have any respiratory symptoms. Magnetic resonance imaging of the brain and spine showed widespread T2 high signal within the gray and white matters and within the spinal cord. She was treated with intravenous methylprednisolone followed by tapering oral prednisolone; this led to resolution of her neurological symptoms. This case highlights that neurological complications can occur secondary to SARS-CoV-2 infection.

Factors influencing intravenous methylprednisolone pulse therapy in Chinese patients with isolated optic neuritis associated with AQP4 antibody-seropositive neuromyelitis optica

This study investigated the factors influencing intravenous methylprednisolone pulse (IVMP) therapy for recovering visual acuity in Chinese patients with aquaporin-4 (AQP4) antibody-seropositive neuromyelitis optica-related optic neuritis (NMO-ON). This retrospective case series included 243 affected eyes of 182 patients (36 male, 146 female) diagnosed with NMO-ON in the Neuro-Ophthalmology Clinic of Beijing Tongren Hospital from September 2012 to September 2020. All patients with AQP4-antibody seropositivity had clinical manifestations of acute ON, excluding other diagnoses and received IVMP treatment at 500 mg/day or 1000 mg/day for 3 days. Primary outcome was the extent of improvement in logMAR visual acuity after IVMP treatment. The therapeutic influences of sex, age, baseline visual acuity, therapeutic intervals, and IVMP dose on acute NMO-ON were analysed. Chi-square tests, Mann–Whitney U-tests, Kruskal–Wallis tests, Spearman’s correlation coefficients, and multiple linear regression were used for statistical analysis. Age ranged between 7 and 80 years (median age, 44; interquartile range [IQR], 29–52) years. Among the 243 eyes, the median improvement in logMAR visual acuity was 0.3 (IQR, 0–0.9). Therapeutic efficacy of IVMP was significantly higher in female than in male patients (Z = 2.117, P = 0.034). The treatment effect gradually decreased with increase in age at onset (Rs = 0.157, P = 0.015), and visual improvement was significantly lower in patients aged > 50 years than in those ≤ 50 years (Z = 2.571, P = 0.010). When patients had low visual acuity at onset, improvements were more obvious (rho = − 0.317, P < 0.001); however, final visual acuity was still low (rho = 0.688, P < 0.001). Therapeutic effect was negatively correlated with therapeutic intervals (rho = 0.228, P = 0.001). Dosage of methylprednisolone (1000 mg/day or 500 mg/day) did not significantly influence treatment efficacy (Z = 0.951 P = 0.342). Therefore, IVMP therapy can improve visual acuity in the affected eyes of patients with AQP4 antibody-seropositive NMO-ON with similar effect at 500 mg/day and 1000 mg/day doses. Sex, age at onset, and therapeutic intervals may influence the efficacy of IVMP in patients with NMO-ON.

A Woman With Subacute Painful Vision Loss

A 51-year-old White woman sought care for vision loss 1 week after a nonspecific upper respiratory tract infection. She reported pain in both eyes exacerbated by eye movement, which lasted for several days, followed by bilateral vision loss to the level of counting fingers–only vision. Optic neuritis was diagnosed, and she was treated with 1 g intravenous methylprednisolone for 3 days. Her vision improved substantially, and the pain resolved during the corticosteroid treatment. However, 1 week later, she woke up with right eye pain and vision loss. She was again treated with 5 days of intravenous methylprednisolone, with visual improvement nearly back to baseline. Two weeks later, she had recurrence of painful vision loss in both eyes. A diagnosis of chronic relapsing inflammatory optic neuropathy was made. Tests for serum angiotensin-converting enzyme, antineutrophil cytoplasmic antibody, antinuclear antibody, Lyme disease, syphilis, tuberculosis, and aquaporin-4-immunoglobulin G antibodies were negative. Serum was definitively positive for myelin oligodendrocyte glycoprotein-immunoglobulin G antibodies at a titer of 1:1,000. Myelin oligodendrocyte glycoprotein-immunoglobulin G–associated recurrent optic neuritis was diagnosed. After her diagnosis of recurrent corticosteroid-dependent optic neuritis associated with myelin oligodendrocyte glycoprotein-immunoglobulin G positivity, the patient was treated with 5 days of intravenous methylprednisolone. The eye pain resolved, and her vision returned to normal. At follow-up evaluation, the patient’s visual acuity, color vision, and visual fields were normal in both eyes, but there was mild bilateral optic disc pallor. She has not had recurrent demyelinating episodes while on chronic immunotherapy. Optic neuritis is an inflammatory demyelination of the optic nerve manifesting as acute to subacute vision loss, classically associated with pain with eye movement. The long-term prevention and prognosis depend on the cause of the optic neuritis.